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원저 : 병원 전 심정지로 응급실에 내원한 환자에서 소생술 중단 기준 결정을 위한 분석

Original Articles : A Retrospective Analysis to Determine Criteria for Termination of Resuscitation (TOR) for a Patient with an Out-of-Hospital Cardiac Arrest (OHCA) who Presents at the Emergency Department (ED)

피인용수 : 12건

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Purpose: As public awareness of medical futility increases, more studies on pronouncement of death and related protocols in the field have been conducted overseas. However, it appears to be hard to declare death in the field in Korea due to a lack of proper treatment procedures for patients with out-of-hospital cardiac arrest (OHCA) under the current emergency medical service (EMS) system. As such, the objective of this study was to establish criteria to determine whether to perform cardiopulmonary resuscitation (CPR) for a patient who visits the ED with OHCA. Methods: CPR results over an 8-year period, from January 2001 to December 2008, from patients with OHCA at Ewha Womans University, Mokdong Hospital were analyzed. The main factors affecting patients that survived for 24 hours after return of spontaneous circulation (ROSC) were identified retrospectively. Results: A total of 782 patients visited the hospital due to OHCA during the study period. Of these, 752 met the inclusion criteria for our study. Of the 752, 162 (21.5%) survived over 24 hours after ROSC. Of the 752, 38 (5.1%) survived to hospital discharge and 18 (2.4%) survived to hospital discharge with good neurologic function. Among patients who survived over 24 hours after ROSC, factors that predicted survival included the presence of a witness (p<0.001), the implementation of CPR by a bystander (p=0.012), a short time from being found to time of arrival at the hospital (p<0.001) and younger age (p=0.042). Factors that predicted non-survival included no witness at the time of cardiac arrest, a prehospital time longer than 20 minutes, bystander CPR but the initial rhythm was asystole. The positive predict value was 95.6%. Conclusion: When an individual has an out-of-hospital cardiac arrest, termination of resuscitation should be considered when there are no witnesses, when there was no bystander to administer CPR, when the initial rhythm was asystole, and when prehospital time was longer than 20 minutes.

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Purpose: Inappropriate use or misuse of emergency medical services (EMS) is a potential waste of resources and a possible diversion of needed service from another patient in need. One of the most serious consequences of inappropriate use of EMS is emergency department crowding. The purpose of this study was to evaluate the appropriateness of EMS use and the propensity of local residents in Daegu to choose particular hospitals. Methods: We obtained study data from Jan. to Feb. 2009 using a prospective survey of patients or their companies that had used EMS. The survey was done by a senior emergency physician who rode in an ambulance with 119 crew members during on-scene assessments and en route to the hospital. The severity of illness/injury was evaluated using the START system/CRAMS scale. We analyzed the appropriateness of EMS use and hospital transport in relation to the severity of the patients problem. We also identified factors that directly influence choice of hospitals. Results: Forty-six cases (36.8%) chose an inappropriate hospital. In 89 cases (71.2%), choice of hospital was done by the patient or his guardian. The most common factor that directly influenced hospital choice was the hospital the patients identified with (50%). Appropriateness of transport to the hospital correlated with problem severity evaluated by the EMS team and by trauma patients (p<0.05). Transport to a higher level hospital (39%) was selected about ten fold more often than transport to a lower level hospital (4%). Conclusion: The appropriateness of local EMS use should be improved with respect to many factors. Local residents have a propensity to choose a large or university hospital for a variety of reasons. Local residents should be continuously educated for appropriative EMS use.

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Purpose: The principle of prehospital transport is that the patient should be transported to the nearest hospital that is suitable for the severity of the illness. Therefore, out-of-jurisdiction transport is improper. The purpose of this study was to understand the present situation and evaluate the appropriateness of out-of-jurisdiction prehospital transport by the 119 rescue group. Methods: Between January and December 2009 we enrolled patients who were transported to the Gwangju Regional Emergency Medical Center by the 119 rescue group, which belongs to Jeolla province. The appropriateness of out-of-jurisdiction transport was based on the transport chart and medical record of the 119 rescue group and categorized into three groups. Results: The total number of patients transported was 440: 78 (17.7%) were appropriate; 329 (74.8%) were inappropriate; 33 (7.5%) patients were very inappropriate. Of the 440, 156 (35.5%) were emergency cases, 147 (33.4%) were sub-emergency cases, and 137 (31.1%) were non-emergency cases. Comparing these data with the triage by the 119 rescue group, the kappa value was 0.368 (p<0.001). The patients or their guardians selected the hospital to which the patient was be transported in 382 (86.8%) cases. The actual transport distance was 40.0 km (range: 26.0 to 50.0) and was significantly longer than the nearest distance to a local emergency center which was 10.0 km (4.0 to 18.0) (p<0.001). Conclusion: Inappropriate out-of-jurisdiction transporting of patients is done frequently. Therefore, guidelines for prehospital transportation according to the triage is necessary. Additionally, the medical director and emergency medicine information center could play a role in selecting a hospital. A fee or a fine of transporters who do not observe the guidelines might limit the proportion of inappropriate transport cases.

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Purpose: Pre-hospital diagnosis and activation of a treatment protocol for ST-segment elevation myocardial infarction (STEMI) is the standard of care in developed countries. But the ability of Korean emergency medical technicians (EMTs) to interpret the 12-lead electrocardiogram (ECG) has not been established. The aim of this study was to compare the diagnostic performance of STEMI done by EMTs before and after an ECG education program. Methods: Seventy three Level-1 EMTs were enrolled from 2006 to 2008 in an eight-week clinical training program. Daily case discussion sessions for interpretation of interpretation of STEMI and acute myocardial infarction, respectively, were followed. before and after the training. EMTs were tested on whether ST elevation was present on the ECG. Correct answer rates of EMTs before and after the education session were compared. We calculated sensitivity, specificity, and accuracy of diagnosis for STEMI. The paired t test was used for statistical analysis. Results: The correct answer rate for all ECG s was 26.8± 19.3% before education and 45.3±26.2% after education. For STEMI ECGs, it was 23.3±28.7% before education and 49.7±36.2% after education (p<0.001). The performance of EMTs in identifying STEMI on the ECG had a sensitivity of 24.0%, a specificity of 28.9%, and an accuracy of 27.6% before education. After education, these scores were improved to 48.6%, 44.3%, and 45.5% respectively. Conclusion: There is significant improvement in ECG interpretation for STEMI through an ECG education program, but accuracy for diagnosis of STEMI by Korean emergency medical technicians was low.

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Purpose: As public awareness of medical futility increases, more studies on pronouncement of death and related protocols in the field have been conducted overseas. However, it appears to be hard to declare death in the field in Korea due to a lack of proper treatment procedures for patients with out-of-hospital cardiac arrest (OHCA) under the current emergency medical service (EMS) system. As such, the objective of this study was to establish criteria to determine whether to perform cardiopulmonary resuscitation (CPR) for a patient who visits the ED with OHCA. Methods: CPR results over an 8-year period, from January 2001 to December 2008, from patients with OHCA at Ewha Womans University, Mokdong Hospital were analyzed. The main factors affecting patients that survived for 24 hours after return of spontaneous circulation (ROSC) were identified retrospectively. Results: A total of 782 patients visited the hospital due to OHCA during the study period. Of these, 752 met the inclusion criteria for our study. Of the 752, 162 (21.5%) survived over 24 hours after ROSC. Of the 752, 38 (5.1%) survived to hospital discharge and 18 (2.4%) survived to hospital discharge with good neurologic function. Among patients who survived over 24 hours after ROSC, factors that predicted survival included the presence of a witness (p<0.001), the implementation of CPR by a bystander (p=0.012), a short time from being found to time of arrival at the hospital (p<0.001) and younger age (p=0.042). Factors that predicted non-survival included no witness at the time of cardiac arrest, a prehospital time longer than 20 minutes, bystander CPR but the initial rhythm was asystole. The positive predict value was 95.6%. Conclusion: When an individual has an out-of-hospital cardiac arrest, termination of resuscitation should be considered when there are no witnesses, when there was no bystander to administer CPR, when the initial rhythm was asystole, and when prehospital time was longer than 20 minutes.

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Purpose: The purpose of this study was to provide an appropriate direction for cardiopulmonary resuscitation (CPR) education for laypersons by analyzing the status of CPR training, bystander CPR, and the prognosis of patients with out-of-hospital cardiac arrest (OHCA). Methods: Data were obtained prospectively by interviews of bystanders who arrived with an OHCA patient between Jan 1, 2009 and Mar 31, 2010. Variables analyzed included CPR education, bystander CPR, and prognosis of OHCA patients. Multivariate logistic regression analysis was performed to identify independent factors for bystander CPR. Results: Nineteen (33.9%) of 56 bystanders (male: 48.2%, age: 48.98±16.87) conducted CPR on an individual having an OHCA. Fourteen (25.0%) of the 56 had CPR education. Of the 14, 8 (57.1%) performed CPR. Among those who did not have any CPR training (p<0.05) 11 (26.2%) conducted it. In a multivariate regression analysis, younger age was a significant predictor for bystander CPR. Previous CPR training and male also appeared to be potential factors although their predictive value was not statistically significant. Conclusion: The rates of CPR training experience and bystander CPR were relatively low in this study. Younger age, male and previous CPR training were associated with the rate of bystander CPR, which is known as a critical factor influencing survival of OHCA patients. In order to increase survival of OHCA patients by raising the bystander CPR rate, systemic CPR education for laypersons should be established.

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Purpose: Pedestrian traffic accident (TA) deaths account for 40% of Korea`s annual TA fatalities. With that in mind, we reviewed the cases of traumatic pedestrian TA patients admitted to emergency medical centers in Korea. We analysed factors affecting the severity of injury in order to investigate risk factors for subsequent traumatic threats. Methods: Prospective methods were applied using a prepared trauma recording format. Trauma records included patient factors (age, gender, occupation, underlying disease), accident factors (time of accident, weather conditions, transportation time, vehicle type causing the accident, influence of alcoholic on both drivers and victims, accident location), and other factors (means of initial hospital admittance transportation). We reviewed medical records to obtain data for vital signs, Glasgow coma scale (GCS), abbreviated injury scale (AIS), injury severity score (ISS), and trauma and injury severity score (TRISS). We divided subjects into 3 groups according to their ISS scores: mild (1-8 points), moderate (9-15 points), severe (16 points). These groups were compared with each other regarding degree of severity? Results: We analyzed data for 23,392 traumatized patients that presented at an EMC. Of the 23,392, 252 (3.1%) were pedestrian TA patients. Among this pedestrian cohort, males 156 patients (male 61.9% and female 38.1%; p=0.332). Mean age was 43.1 (±19.9). Severity was greater in those over 40 years of age compared those under 40 (p=0.000). Farmer`s had the greatest severity than patients in other occupations (p=0.004). Those with an underlying disease showed a higher degree of severity (p=0.028). The most common accident site was city roads (85.7%) but the degree of severity at such sites did not was not significantly greater (p=0.052). Sports utility vehicle (SUV) had the highest rate of accident severity (p=0.004). Cases involving drunken drivers had victims with higher severity (p=0.005). Regarding injuries inflicted on different body parts, the highest degree of severity was associated with abdominal trauma, followed by head & neck and thorax (p=0.000). Conclusion: Factors that increase the rate of fatalities pedestrian TAs are: older age, underlying illness, working in the agricultural sector, driving an SUV, the patient being in a drunken state.

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Purpose: To determine the accuracy of a simple radiologic images as a diagnostic tool for intra-articular fractures of the distal radius (IAF). Methods: This study proceeded prospectively from April 2008 to December 2009. We let 25 ERs (emergency residents) interpret the radiologic images of 45 patients who had injuries of their wrists and presented to a hospital. We used surgical findings or multidetector computed tomography (MDCT) to confirm the final diagnosis of enrolled patients. Finally, we evaluated the sensitivity, specificity, and accuracy of simple radiologic images of IAF. We also compared test performance characteristics between the four grades of the ERs (1st, 2nd, 3rd, and 4th years) via Mann-Whitney and Kruskal-Wallis tests. We considered differences to be significant, if p<0.05 Results: Of 45 patients, 40 (88.9%) had fractures of the distal radius; of the 40, 25 (62.5%) had IAF. There were no differences in sensitivity, specificity, or accuracy between the four grades of the ERs (p=0.86, 0.76, 0.49). The sensitivity of simple radiologic images for diagnosing IAF was 0.69; specificity was 0.77; accuracy was 0.72. Conclusion: In this study, we found that simple radiologic images as the primary diagnostic tool for intra-articular fractures of the distal radius were not completely adequate. Therefore, ERs should carefully consider using MDCT imaging to diagnose patients who suffer from wrist pain.

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Purpose: To describe the current status of airway management for trauma patients in the emergency department (ED) and to evaluate the success rate and associated factors for selecting the Glidescope video laryngoscope. Methods: This was a retrospective observational study of prospectively collected data from the Koran Emergency Airway Management Registry in two university hospitals between April 2006 and March 2010. The study population included all trauma patients presenting at the ED who required emergency airway management. Demographic and airway related parameters were collected. The success rate was compared between the Glidescope and the direct laryngoscope. Factors associated with selecting the Glidescope were analyzed using multiple logistic regression. Results: Among the 1,974 patients who received airway management in the ED during the study period, 341 were identified as trauma patients. The Glidescope was used in 130 (38%) of the patients. Difficult airway was identified in 46.9% of the Glidescope group compared with 22.6% in the direct laryngoscope group (p<0.001). Success rate on the first attempt was not different between the direct laryngoscope and the Glidescope. The Glidescope was selected in favor of cervical immobilization, difficult airway, and senior grade resident. Conclusion: Among intubated patients in the ED, trauma patients accounted for 17.6%. The Glidescope video laryngoscope was selected in 38% of cases. It was usually used in cases of difficult airway such as cervical immobilization by senior grade residents.

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Purpose: The aim of this study was to analyze the characteristics and prognosis of intraperitoneal and retroperitoneal solid organ injuries after trauma. Methods: We analyzed computed tomography (CT) data for 232 patients who had injury to solid abdominal organs between January 2002 and June 2009. The patients who had solid organ injury on CT were categorized into intraperitoneal, retroperitoneal and intra/retroperitoneal injury groups. Medical records were reviewed retrospectively, and data regarding the sex and age of patients, mechanism of injury, initial hemodynamic status, Revised Trauma Score (RTS), Abbreviated Injury Scale (AIS), Injury Severity Score (ISS), amount of transfusion, admission rate to intensive care unit (ICU), and mortality were collected and analyzed. Injury severity of solid organs was classified according to the American Association for the Surgery of Trauma (AAST) grading system. Results: The intraperitoneal injury group had 131 patients, the retroperitoneal injury group 49 patients, and the intra/retroperitoneal injury group 52 patients. The intra/retroperitoneal injury group exhibited low blood pressure, a large number of packed red blood cells that were transfused, and high ISS and abdominal AIS. They tended to stay longer in the ICU and showed a higher mortality. Conservative management was the most common therapeutic modality for all 3 groups. Conclusion: The intra/retroperitoneal injury group showed higher fall for the mecahnism of injury, a lower initial blood pressure and a larger number of packed red blood cells that were transfused compared with the other groups. Therefore, physicians should rapidly identify those with a poor prognosis at initial presentation and make a decision quickly when they are caring for intra/retroperitoneal injury patients.

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Purpose: Benign paroxysmal positional vertigo (BPPV), the most common cause of vertigo, can be treated with a simple repositioning maneuver. But there are few reports about the underlying mechanism of this problem or about prognostic factors for recurrent BPPV, which is frequently encountered after symptoms have subsided. Among reported prognostic factors in BPPV, repositioning timing in the treatment of BPPV has been considered by some physicians to be an important one, especially for recurrence. Our study was done to demonstrate, in patients with BPPV, the effect of early repositioning therapy on disease recurrence. Methods: We enrolled consecutive 73 patients who had been diagnosed BPPV in the department of emergency and otolaryngology in Seoul Samyook hospital between January 2009 and June 2009. All patients who were diagnosed with BPPV immediately had appropriate canalith repositioning maneuvers (CRM) done (depending on the type of BPPV) by emergency department or otolaryngology department doctors. Patients were classified according to the timing of treatment after onset (within 24 hours, after 24 hours). We prospectively compared recurrence rates between the two groups. Results: Of the 73 patients, recurrence was seen in 16 (22.2%): 4(11%) of 36 patients in the early treatment group (within 24 hours), and 12(31.4%) of 37 patients in the delayed group (after 24 hours). The between group difference in recurrence rates was significant (p<0.05, chi-square test; p=0.053, logistic regression). The incidence of recurrence of BPPV was much higher in older patients (p<0.05, t-test. logistic regression>0.1). Conclusion: Recurrence of BPPV is affected by early CRM after symptom onset. Doing CRM as soon as possible after symptom onset is important